Sterile gowns for spinal anaesthesia – environmental cost without clinical gain?

We read with interest the article by Ledda et al. [1], which highlights a drive to change from single-use to reusable gowns to be more environmentally sustainable. While laudable, we feel that it does not consider wider changes to our practice which could have an impact of greater magnitude.

Standard practice in many UK centres is to wear a sterile gown for spinal anaesthesia to reduce the incidence of infective complications. This practice is mandated in the 2014 Association of Anaesthetists guidance [2]. However, this practice is not standard globally. In the UK, practice varies for other neuraxial procedures, e.g. many doctors from medical specialities do not wear a sterile gown for lumbar punctures.

Most anaesthetists are cognisant of the risk of infective complications. However, the incidence of infection following single-shot spinal anaesthesia is very low. The 3rd UK National Audit Project (NAP3) reported only two cases of vertebral canal abscess and one of infective meningitis associated with approximately 325,000 spinal anaesthetics [3]. It noted failings of asepsis and specifically referenced the importance of sterile drapes and use of facemasks, but did not specifically mention sterile gowns. Beyond NAP3 there is very little evidence for the use of sterile gowns. Only a single randomised controlled trial has been identified [4], which investigated gowning on the incidence of catheter tip colonisation in lumbar epidural for labour analgesia. Siddiqui et al. concluded that the use of gowns did not affect catheter colonisation.

The volume of waste generated using sterile gowns for spinal anaesthesia is significant. In NHS Tayside, a health board with a patient population of 416,090 (2017 Census), we undertook 2877 spinal anaesthetics in 2022. Gowns generated nearly half a metric tonne of carbon dioxide equivalent (CO₂e) from disposal in clinical waste. These gowns are manufactured in China, and it is challenging to estimate the (likely extensive) additional environmental cost of production and shipping to the UK. As stated, NAP3 estimated that there were approximately 325,000 spinal anaesthetics undertaken in the UK in 2009 [3]. Using a sterile gown for every spinal anaesthetic generates vast amounts of CO₂e.

Many anaesthetists seem to be receptive to a change of practice in this area. Tuohey et al. raised similar concerns in 2023 and called for a change in practice in the UK and Australasia [5]. When we surveyed 51 anaesthetists in NHS Tayside, 89.9% of respondents were receptive to changing their practice if supported by a change in guidance. While changing to reusable alternatives may help environmentally and financially, it seems that high quality asepsis for single-shot spinal anaesthesia can still be achieved without the use of a sterile gown, and that individual clinicians should be encouraged to choose what best suits their practice. National guidance mandating this practice, including that of the Association of Anaesthetists, is a barrier to change and to any future research into this area.